The content and effectiveness of Graduate Medical Education (GME) is an important determinant of the quality and cost of our health care system. Location of GME affects the size and geographic distribution of our physician workforce, thereby influencing access to care.
Given this important relationship and the investment of tax-payer dollars to fund GME, it is essential to resolve the longstanding GME policy controversy which impairs coordination of GME policy with national needs. Efforts to break the GME policy logjam over the past 30 years have faltered in spite of multiple recommendations by the Council on Graduate Medical Education (COGME), which addressed the issues through numerous reports but with inadequate resources and influence.
The Accreditation Council for Graduate Medical Education (ACGME) effectively assures the quality of training programs. However, other increasing concerns about GME funding and accountability have created enough dissatisfaction and controversy to prompt a Congressional request for an Institute of Medicine (IOM) report, released in July, 2014 (2). This report proposed major reforms which would create a GME system with greater transparency, accountability and strategic direction that aligns with national needs. Stakeholder response to the IOM Report currently is being evaluated by Congress in the Health subcommittee of the House Energy and Commerce (E&C) committee. Their input from various stakeholders has been complex and lacking in consensus, thereby perpetuating the GME policy logjam, creating a daunting challenge and thereby decreasing prospects of any comprehensive legislative GME reform in this session of Congress.
Since the introduction of the “resident physician shortage reduction act of 2009" (S. 973) and its companion bill in the House (H.R. 2251), multiple bills have been introduced to achieve a 15 percent increase in the aggregate number of Medicare-sponsored residents in approved GME programs. The most recent attempt was S. 1148 and H.R. 2124, introduced in April of this year. All of these bills have attempted to lift the cap on Medicare-funded GME positions, ostensibly to support the training of critically needed primary care physicians and non-primary care specialists. However, none have provided any meaningful provisions to ensure that new residency slots are dedicated to primary care specialties. Instead, they include specific distributional criteria which would disproportionally increase Medicare funding for non-primary care specialty training.
Thus, current GME expansion legislation continues to elicit stakeholder controversy. It does not incorporate evidence and policy based national physician workforce solutions and therefore has not engendered broad support.
To progress beyond this inertia, we propose legislation that creates a platform for GME reform by building on the only existing body in the U.S. today that represents a synthesis of professional and governmental oversight, one with a three decade history, a culture of expertise, and the depth of understanding of the issues to fully address them — COGME. In addition to placing a high priority on accountable oversight, this legislation also introduces measures to address long under-supported physician training needs: primary care and rural practice; in addition to providing COGME enhanced authority, we propose sustainable support for the Teaching Health Center (THC) and Rural Training Track (RTT) GME programs and their integration with the Veterans Administration (VA) GME program.
New Role For COGME
Strengthening COGME would facilitate finding solutions to GME governance, financing, and expansion of the physician workforce by enhancing the existing forum, providing meaningful data, and working within an established process to reach stakeholder consensus needed for GME reforms. Presently no other professional institution or governmental organization exists to provide effective oversight for GME beyond the system of resident and fellow payments adhered to by the Centers for Medicare and Medicaid Services (CMS); this system provides funding to sponsoring institutions based on annual cost reports filed according to CMS regulatory guidelines, but currently no institution is responsible to assure Congress that GME spending is meeting the physician workforce needs of an evolving health care system.
Our proposed legislation builds on COGME's already established national leadership role by enabling it to give credible, evidence-based recommendations to Congress and the Secretary of Health and Human Services (HHS). Council membership must be broadly representative, with professional organizations serving in an ex-officio role in an effort to achieve consensus. The 21st Century COGME must be provided data and be able to contract with consultants and experts in workforce issues, health policy, economics, education, as well as consulting professional organizations, GME residency and fellowship program directors, and the public. Adequate staffing is required to enable the necessary data collection and analysis for COGME recommendations. All of this requires $4 million per year from the HHS Secretary's budget.
This legislation would establish a revised charter for COGME explicitly defining its authority, objectives, and scope of activities, duties, membership, reporting relationship, and meeting parameters. A key initial mandate would be to develop a comprehensive national GME strategic plan with defined goals and objectives and a clear timetable. A key factor in developing the aforementioned national strategic plan would be immediate analysis of the stakeholder input to the Health Subcommittee of the Energy and Commerce Committee, with the goal of developing consensus. This would require a minimum of 18-24 months.
An attractive feature of our proposal is that it eliminates the necessity to create a new organization. Also, it facilitates utilization of established workforce research centers in both the public and private sector. This legislation establishes the COGME in the Office of the Secretary of HHS, but with parallel responsibilities to report to the appropriate Congressional Committees, and the HHS Secretary.
The Chair of COGME should be appointed by the Secretary of HHS. The Chair's qualifications should include: 1) understanding of the development of policy in the public interest; 2) expertise in a discipline relevant to creating GME policy, including but not limited to health economics, workforce development, management, organizational principles, health services research, or education; 3) knowledge of health care delivery and its evolving nature; and 4) no direct relationship with or direct responsibility for any GME program or programs.
Primary Care GME Expansion
A prominent emphasis of the E&C Committee stakeholder responses has been the importance of ambulatory training in the community, team-based care, and the importance of enhanced training in primary care to produce enough physicians especially in urban and rural shortage areas. The Teaching Health Center Graduate Medical Education (THCGME) program is accomplishing these goals. Recently validated by outcomes from its first four years, the program has achieved bipartisan Congressional support, as evidenced by continued funding provided by the recently enacted 2015 Medicare Access and CHIP Reauthorization Act (MACRA).
Sixty THCGME programs in 24 States are currently training over 550 residents in primary care, dentistry, and psychiatry, with an expansion to 800 positions proposed for the July 2016-July 2017 residency year. The program is supported by $230 million over five years authorized by the Affordable Care Act (ACA) that will expire at the end of FY2015. THCGME programs are located in community-based ambulatory care settings, such as Community Health Centers (CHCs), and serve a large number of Medicaid patients. Those who train in these underserved areas are likely to remain and practice in these same or similar settings, with location of residency training often predicting practice style regarding quality and cost.
The MACRA recently provided $60 million per year for FY2016 and FY2017, through the Medicare affluent beneficiary tax mechanism, to continue funding of the current THCGME program. However, a more sustainable and greater level of funding is required to retain THCGME viability and to protect the $230 million ACA investment. We propose to increase MACRA support for THCs in FY2016 and 2017 by an additional $60 million to $120 million per year; this is necessary to support 800 positions at a per resident amount (PRA) of $150,000 per year, an amount required because of the increased cost of diverse faculty and infrastructure needed for this unique curriculum.
To meet documented primary care needs in the near future, at least 2,000 new physicians should be added to the workforce annually, requiring support of 6,000 positions since most programs are three years in duration. Expanding the successful THCGME program to 1,600 total positions as of FY2018, with an average production of about 530 graduates annually who are prepared to serve in high-need environments, could remove at least some of the pressure from an evolving health system in need of physicians. Thus, we propose an additional three years of MACRA support for the THCGME program at $240 million per year, thereby allowing creation of 800 additional positions in new programs. The total five-year MACRA cost for sustaining 1,600 positions through FY2020 would be $960 million. This $840 million expenditure over currently committed MACRA support would provide five years of expanded and sustained funding. The THCGME program would continue to be administered by the Bureau of Health Workforce of the Health Resources and Services Administration (HRSA).
Overcoming Obstacles In Implementing Rural Training Tracks
Rural physician production from GME is now less than 5 percent of the total annual physician workforce. By comparison, the current rural physician workforce makes up 11 percent of all physicians and provides a significant portion of the care for the nearly 20 percent of the American population living in a rural area. In the long term, this cannot sustain a rural physician workforce adequate to care for these 62 million Americans, who have higher rates of mortality, disability, and chronic disease than urban dwellers.
Rural Training Tracks (RTTs) were developed in the late 1980's to help create location based community education programs in family medicine that over time would help create the workforce needed for rural America. A RTT is an alternate form of residency training, where the 1st year of training is in an urban setting, and the 2nd and 3rd years are typically in a rural setting associated with a rural hospital, or where greater than 50 percent of the residents' training occurs in a rural location.
Since most residency programs are located in urban areas, RTTs provide a training alternative that increases physician placement and retention in rural and underserved communities. Although the Balanced Budget Act of 1997 placed a cap on new residency positions supported by Medicare, the 1999 Balanced Budget Refinement Act allowed for new RTTs to be an exception to this cap. In 2003 the Medicare Prescription Drug, Improvement and Modernization Act authorized the redistribution of GME positions with the intent of increasing primary care and rural training.
Unfortunately the regulations promulgated under these acts have thwarted their intent and resulted in very few new rural residency positions. Current sources of funding for residency training programs include the federal government through Medicare and Department of Veterans Affairs (VA) GME funding, state governments through Medicaid GME and direct state support, and THCGME funding and revenues generated from patient care services provided by the residents and faculty. Of these, Medicare GME support is critical for financial survival, but CMS rules governing the funding of new residency positions place severe restrictions on the ability of many potential RTT programs to qualify for Medicare GME support.
Changes in CMS funding rules should be recommended to the HHS secretary by COGME and new regulations developed by CMS as soon as possible. In addition, one of the COGME Board members should be a representative of the RTT GME Collaborative.
Integration of Veterans Administration (VA) GME with RTTs
Twenty-eight percent of veterans live in rural areas. They frequently do not have convenient access to VA facilities and would benefit greatly from local access to care. The recent Veterans Access, Choice and Accountability Act of 2014 includes $10 billion in emergency spending to outsource care to communities and $5 billion to hire additional doctors, nurses, and other clinical staff. It also establishes 1,500 new GME positions, which by law are focused on primary care, mental health, and other specialties the Secretary of VA deems appropriate. Thus, veterans now have the option of obtaining some of their care at community health or rural health clinics or from other local sources of care, with their specialty care coordinated through a regional VA facility.
Because of the legislation's language and intent, the VA will be locating these new resident positions in smaller communities and VA Medical Centers. And due to the VA's policy and payer constraints, VA must partner with existing or new affiliated entities in these communities, a need which aligns VA GME with THCs and RTTs. Encouraging and facilitating new RTT and THC residency positions in rural and under-served locations are important enablers for VA GME success and will bring critical workforce into these areas to the benefit of both the VA and these communities.
A Path Forward
In recognition of the present challenge faced by Congress in legislating GME reform, we have proposed a legislative pathway to breaking the GME policy logjam. This legislation would be built upon a foundation of a rejuvenated COGME. As a means of immediately targeting our most critical primary care needs, we propose increased and more sustainable support for THCs. In addition, both rural primary care and non-primary care specialty needs are addressed by provisions which support RTTs and their potential integration with recently legislated increased VA GME support.
The United States faces a shortage of physicians as a consequence of aging of the population, the growth of chronic illnesses such as diabetes, retirement of practicing physicians, and maldistribution of physicians across the country. While the growing number of other care givers such as advanced practice nurses, physician assistants, and pharmacists will mitigate these shortages they cannot totally compensate for them.
Depending upon local conditions, the needed ratio of primary care physicians to other specialists will vary. In some communities the need may be greatest for general surgeons or child psychiatrists. A major responsibility of a reformulated and adequately resourced COGME will be a state-by-state assessment of overall physician needs and the appropriate distribution of the various GME programs and resident FTEs. In the interim, however, it is critical that currently available opportunities to prepare residents for practice in underserved and rural areas through THCs and RTTs not be diminished, but rather enhanced.
Our proposed legislation breaks the longstanding GME policy logjam by utilizing an immediate and a long-term strategy, built upon the constructive contributions of over 120 responses to the Health Subcommittee of the Energy and Commerce Committee's request for input on the recent IOM GME Report. Funding via the recently developed Medicare affluent beneficiary tax provision in MACRA allows enactment without further adding to the Federal deficit.